Measure ID

Percentage of patients aged 3 through 17 years of age, who undergo general anesthesia in which an inhalational anesthetic is used for maintenance AND who have one or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.

The purpose of this process of care measure is to reduce the incidence of postoperative nausea and vomiting in pediatric patients.

Measure Type

Postoperative nausea and vomiting (PONV) is a common and unpleasant outcome of anesthesia care that can lead to other complications, lengthening the patient’s recovery period after surgery2. Effective management of PONV leads to optimal patient outcomes and comfort during the postoperative period.3 Combination therapy that includes two prophylactic pharmacologic anti-emetic agents of different classes is most effective when managing PONV in children.4,5

A separate PONV risk model should be considered for pediatric patients as many proven risk factors for adults are difficult to assess or do not apply to children.6 The independent PONV risk factors identified for pediatrics include duration of surgery greater than 30 minutes, age greater than 3 years old, positive history of PONV (individual and/or immediate family) and strabismus surgery.6 Although including a prophylactic anti-emetic administration protocol that considers such risk factors has shown to reduce the incidence of PONV, there is high variability in this outcome.7,8

Measure Time Period

4 hours before Anesthesia Start to PACU Start


All patients, age 3 through 17 years of age, who undergo any procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have one or more additional risk factors for POV.

POV Risk Factors:

Success Criteria

Patient receives combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively

Anti-emetic therapy:  The recommended pharmacologic anti-emetics for PONV prophylaxis in pediatric patients at risk for moderate to severe PONV include (but may not limited to):

  • 5-Hydroxytryptamine (5-HT3) Receptor Antagonists (Recommended as the first choice for prophylaxis for POV in children)
  • Glucocorticoids
  • Anticholinergics
  • Antihistamines
  • Butyrophenones
  • Phenothiazines
  • Phenylethylamines
  • NK-1 Receptor Antagonists

Note: In addition, propofol infusion is accepted as one of the antiemetic options for this measure. The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.

Other Measure Details
  • For a case to be included for the PONV 02 measure, the patient must have received inhalational general anesthetic for maintenance purposes AND have two or more risk factors for POV. This measure determines maintenance using the Halogenated Gases Used and Nitrous Oxide Used phenotypes and must return value code > 1.

  • Values for flows and gases will be assessed and considered artifact if less than the following ranges and the patient did not receive any other inhalational general anesthetics greater than these ranges:

    • Nitrous Oxide Flows: <0.2 L/min
    • Isoflurane Insp %: <0.3%
    • Sevoflurane Insp %: <0.4%
    • Desflurane Insp %: <1.2%
    • Nitrous Oxide Insp % <20%
Provider Attribution

Provider(s) signed in at Induction End.

Method for determining Responsible Provider:

  1. Provider signed in at Anesthesia Induction End. If not available then,
  2. Provider signed in at Anesthesia Induction Start. If not available then,
  3. Provider signed in at Surgery Start. If not available then,
  4. Provider signed in at Patient in Room. If not available then,
  5. Provider signed in Anesthesia Start.
MPOG Concept Used


  • 3297  Enflurane Exp %
  • 3298  Enflurane Insp %
  • 3006  Isoflurane actual consumption (ml)
  • 3007  Desflurane actual consumption (ml)
  • 3260  Isoflurane Exp %
  • 3265  Isoflurane Insp%
  • 3280  Desflurane Exp %
  • 3285  Desflurane Insp %
  • 50420 Cardiopulmonary bypass – Isoflurane vaporizer turned on
  • 3008  Sevoflurane actual consumption (ml)
  • 3270  Sevoflurane Exp %
  • 3275  Sevoflurane Insp %
  • 3503  Sevoflurane (mmHg)
  • 3250  Nitrous Insp %
  • 3255  Nitrous Exp %


Class: 5-Hydroxytryptamine (5-HT3) Receptor Antagonists

  • 10335 Ondansetron
  • 10164 Dolasetron
  • 10208 Granisetron
  • 10711 Palonosetron


  • 10400 Scopolamine Patch
  • 10399 Scopolamine
  • 11040 Butylscopolamine


  • 10257 Dimenhydrinate
  • 10160 Diphenhydramine
  • 10635 Meclizine


  • 10169 Droperidol
  • 10210 Haloperidol

Neurokinin-1 Receptor Agonists

  • 10035 Aprepitant
  • 10719 Fosaprepitant


  • 10374 Promethazine
  • 10373 Prochlorperazine


  • 10147 Dexamethasone
  • 10296 Methylprednisolone


  • 10297 Metoclopramide
  • 10377 Propofol (Infusion only)

PONV Medical Reason Exclusion

  • 50046 Medical Performance Exclusion- PONV

PONV Risk Factor- History of PONV/Motion Sickness:

  • 70225 Assessment and Plan - Comments
  • 70302 Assessment and Plan- Anesthetic Consideration
  • 70338 General- PONV Risk Factors
  • 70339 General- PONV Risk Total Score
  • 70080 General- Previous Anesthetic Problem
  • 70102 Misc- Motion Sickness
  1. Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2007;105(6):1615-1628, table of contents.
  2. Gillmann HJ, Wasilenko S, Zuger J, et al. Standardised electronic algorithms for monitoring prophylaxis of postoperative nausea and vomiting. Archives of medical science : AMS. 2019;15(2):408-415.
  3. Collins AS. Postoperative nausea and vomiting in adults: implications for critical care. Critical care nurse. 2011;31(6):36-45.
  4. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2014;118(1):85-113.
  5. Shen YD, Chen CY, Wu CH, Cherng YG, Tam KW. Dexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials. Paediatric anaesthesia. 2014;24(5):490-498.
  6. Eberhart LH, Geldner G, Kranke P, et al. The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesthesia and analgesia. 2004;99(6):1630-1637, table of contents.
  7. De Oliveira GS, Jr., Castro-Alves LJ, Chang R, Yaghmour E, McCarthy RJ. Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies. British journal of anaesthesia. 2012;109(5):688-697.
  8. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC anesthesiology. 2018;18(1):162.
Measure Reviewer(s)
Next Review: 2024
 Date Reviewed  Reviewer  Institution  Summary  QC Vote






Published Date: 03/2018
 Date  Criteria  Revision
 10/21/2022  Multiple

 Inhlational general defined with new Nitrous and Halogenated gas phenotypes

 Strabismus exclusion uses Strabismus phenotype

 Surgery duration uses Case duration phenotype

 Modified Measure Start, - 4 hours before Anesthesia Start

 Modified Measure End, PACU Start

 Labor Epidural exclusion now uses Obstetric phenotype

 04/20/2022  Inclusion  Updated inhalational gas threshold values
 08/04/2020  Success  Modified to use note entered time if observed time is not available
 01/22/2020  Inclusion  Added time bounds for receiving general anesthetic
 09/30/2019  Exclusion  Added 'Transported to ICU' as exclusion